Accidental Overdose - or Suicide?

 

There has been a lot of news recently about the significant increase lately in the number of drug overdoses resulting in fatalities. Most of these overdoses are labeled “accidental,” and surely many of them are. Of course, if drugs have been secretly laced by dealers with something dangerous like fentanyl, and the addict is unaware of that, the overdose can indeed be accidental. Although not necessarily even in that case, because news about the fact that dealers are lacing other drugs with this one has been widely reported in the press, and many addicts know other addicts.

 

I suspect that a considerable portion of these “accidental” overdoses are actually suicides, either through specific intent at that particular moment, or through strong chronic suicidal intent leading to carelessness that will certainly cause death, but at some unpredictable time.

 

There is no way to know for certain, obviously, but I would like to discuss the deaths of two celebrities to illustrate my thesis here: actor Phillip Seymour Hoffman and Americana singer-songwriter Townes van Zant.

 

Van Zandt wrote numerous songs, such as "Pancho and Lefty", "For the Sake of the Song", "Tecumseh Valley", "Rex's Blues", and "To Live Is to Fly", that are widely considered masterpieces of American songwriting.  

 

Van Zandt died on New Year's Day 1997 from cardiac arrythmia caused by health problems stemming from years of substance abuse.  In 1994, he was admitted to the hospital to detox, when a doctor told Jeanene Van Zandt that trying to detox Townes again could potentially kill him. He grew increasingly frail during the mid-1990s, with friends noting that he seemed to have "withered.”

 

The evidence for my viewpoint comes in the shape of the lyrics of a song he wrote called “Waiting Around to Die.” I suspect that this is exactly what he was doing.

 

The lyrics:

Now I'm out of prison
I got me a friend at last
He don't drink or steal or cheat or lie
His name's Codine
He's the nicest thing I've seen
Together we're gonna wait around and die
Together we're gonna wait around and die

 

 Hoffman told friends he feared he would die of a heroin overdose weeks before his body was found on the floor of his Manhattan bathroom with a needle sticking out of his left arm. The star, who was found with 70 bags of heroin and 20 used needles in his home, returned to AA in December after relapsing into three-day binges. When asked how serious his addiction was, he replied: “If I don't stop now, I know I'm going to die.” And die he did. On 2/2/14, he was found dead in his New York apartment with a needle in his arm. The New York City Chief Medical Examiner said that he died of an accidental overdose of drugs, but one has to wonder how an “accident” can be predicted with such precision.

Time to Get a Second Opinion?

 

If a mental health provider has you on a whole lot of different psych meds on the basis of a cursory diagnostic interview without much follow up and almost no attention to what is going on in your life currently, it is time to see somebody else.

In the July issue of Clinical Psychiatry News, Nicolas Badre and David Lehman discuss what is known as “malignant polypharmacy” –  the tendency of some psychiatrists and psychiatric nurse practitioners to confuse symptoms that appear in different forms with a variety of different psychiatric diagnosis. 

They then make multiple diagnoses – many of which are not really separate conditions co-occurring with a primary diagnoses – and prescribe a variety of medications. Many of these are not only not indicated but may interfere with each other or produce unnecessary side effects. This diagnostic and treatment stew also creates a great deal of confusion for the patient about exactly what they are being treated for.

An example they give is a patient who comes to a new doc having been diagnosed with bipolar II (a b.s. diagnosis to begin with), high anxiety, split personality, post-traumatic stress, insomnia, attention deficit and depression.” The medication list of such a patient may include a stimulant and a tranquilizer (uppers and downers and bears, oh my!), a mood stabilizer, two antidepressants, and a low dose antipsychotic!

Overprescribing of dangerous meds is another problem. The Wall Street Journal exposed abuse of Adderall prescriptions by telehealth organizations. One story (8/19/22) was about a man with substance abuse who was given an Adderall prescription after a “30 minute consult” with a Nurse Practitioner who’s specialty was family medicine with no psych training. 

Reports show the company sometimes prescribed after just a 10 min consults, giving 90 day scripts with limited or no follow up. The NP was making 20k per month. Patients were charged $79 to subscribe. Some of these “providers” were given $10 per script per month with some having over 2,000 of them filled per month.

 

In adolescents, overprescribing has become pandemic. The New York Times (8/27/22) reported on the common medical practice of “the simultaneous use of multiple heavy-duty psychiatric” medications among adolescents. “Such medications are too readily doled out, often as an easy alternative to therapy that families cannot afford or find, or aren’t interested in.” 

The medicines, “generally intended for short-term use, are sometimes prescribed for years, even though they can have severe side effects,” and a number of psychiatric medications “commonly prescribed to adolescents are not approved for people under 18.”

 

While of course, as the authors of the Clinical Psych article point out, there is in psychiatry a high rate of co-occurring conditions, a lack of treatment specificity, and poor understanding of causes. However, a complete work up includes the doctor looking at all of the patients’ symptoms, biological factors, psychological factors, and social factors, as well as the course of the patient’s illness. 

Are the symptoms present all the time, or do they come and go depending on environmental factors? If the latter, what factors are we speaking of? Does one diagnosis preclude another, like bipolar and unipolar depression? Is there a family history of certain disorders?

 

Did your clinician even ask about any of this? Like I said, if not, time to find a new one.

In a new video, I discuss family issues that feed into guilt in women trying to balance career and family

https://www.youtube.com/channel/UCPjK28Du95eX2ZdWTT5_6TQ

Who Influences Teens More: Peers or Family?

Harvard psychologist Howard Gardner states in his book Changing Minds that by about age 10 a child’s peers rather than parents assume primary importance in the child’s decisions about what to do, especially in the United States. They are, he says, inclined to imitate those peers. This has become almost conventional wisdom in a lot of psychology schools. 

Well of course peers do have a significant influence on kids, especially teenagers, but the question of who has more influence on them is quite a bit more complicated. The most obvious complication is that in the United States of recent years, there are a lot of different peer groups from which to pick. So what determines if a kid wants to be, say, a Goth or a jock? Even back when I went to high school back in the mid sixties in Southern California, there were surfers, greasers, jocks, “brains,” “soches,” guys in rock bands who wanted to grow long hair like the Beatles but were told by the boy’s vice principal to cut it, theater people, churchy people, and a lot of kids who didn’t fit any of classifications or straddled two or three of them.

With which peers adolescents choose to associate is not an accident of fate or necessarily the inclination of the developing child’s true-self tendencies. If their parents were pretty good about letting them learn to lead their own lives and develop their own opinions, then which peers they hung out with was most likely a result of their own developing self-actualization. But in more dysfunctional families, the kids’ behavior, as I have repeatedly discussed in this blog, is designed to stabilize unstable parents and maintain family homeostasis. If this is the case, the parents’ seeming needs steer kids in certain directions regarding their peers. For example, it may determine which kids turn into bullies and which turn into the bully’s victims.

This sort of question has been relevant in psychiatry also. In the past, parents would allow their acting-out teens to be placed in psychiatric hospitals, where shrewd but unethical hospital administrators and psychiatrists blamed the adolescent’s emotional problems and misbehavior – or even their suicide attempts - on cultural phenomena such as heavy metal music. This way, the parents would not feel that they were being scrutinized or blamed, and would gladly pay up.  Some hospitalized kids were kept there for months until their insurance ran out and then summarily discharged. Peer pressure was another scapegoat offered up by hospitals to these parents.

Gardner also mentions how American children even by pre-adolescence have “evolved strong preferences” that may not align with those of their kin and/or ethnic group, and can often state their opinions strongly and stand their ground in disputes. Again, I can’t argue that this doesn’t happen, but IMO this is way over-generalized. They may do that with certain opinions and planned activities, but not dare to question others. Opinions and plans are hardly an all-or-nothing phenomenon when it comes to potentially challenging family homeostasis. If an opinion is expressed and in response Mom sticks her head in the oven while other family members massively invalidate the person expressing the opinion, children standing their ground is almost never the result. And families are all completely different from one another when it comes to which shared internal conflicts are present over certain things, how severe those conflicts may be, or how many of them exist.

Book Review: Building a Life Worth Living: A Memoir by Marsha Linehan

The predominant and most widely-used school of thought in use for the psychotherapy of borderline personality disorder (BPD) is called dialectical behavior therapy (DBT). Marsha Linehan, a psychologist at the University of Washington, was the person who came up with the theory and treatment ideas. The treatment paradigm has been shown in studies to be somewhat effective in reducing some symptoms of the disorder, but mostly ineffective in helping patients solve their problems with love and work.

She believes that a combination of a genetic propensity to be over-reactive combines with a so-called “invalidating environment” to produce the disorder. Studies  that attempt  to identify genetic propensities tend to have a major flaws in distinguishing normal neural plasticity in response to the environment from purely genetic effects, although the combination of a baby that tends towards being reactive and a parent with attachment issues would be problematic – an example of gene-environment interaction rather than just genetics.

The invalidating environment is clearly that in the patient’s family of origin, although this is seldom spelled out in the DBT literature.

Interestingly, in 2011. Linehan, in a story in the New York Times, “…admits that when she was younger, she "attacked herself habitually, burning her wrists with cigarettes, slashing her arms, her legs, her midsection, using any sharp object she could get her hands on." She added, “I felt totally empty, like the Tin Man."  Self injurious behavior and feeling empty are two of the hallmark symptoms of BPD.  Did she have the disorder?  According to the article at least, BPD is a diagnosis "that she would have given her young self."

So I was intrigued when she recently published her memoir. I was particularly interested in hearing about her family of origin and hints of any shared psychodynamic conflicts they may have had, a phenomenon that she appears to be clueless about with her patients. I had wondered why, if she came from such a family, she rarely wrote about how to address invalidating family members, as opposed to merely teaching patients “radical acceptance” of their parents’ ongoing behavior so they react much less.

So if she herself had BPD, and if an invalidating environment is one of two main causes of the disorder as she theorizes, I've long wondered how come she does not address this very much in her treatment plan. She says she sometimes does family therapy, but mentions it only briefly and without any details both in her memoir and her primary book about DBT.

While I cannot be certain of anything about her family based just on what she chooses to reveal in her memoir, the family’s conflicts over gender roles – particularly career aspirations for women – and religion just seem to jump off the page of her memoir. So the following forms the basis for my speculations.

She herself draws the parallel between her mother’s experiences growing up and her own conflicts with her mother. The mother’s parents were described as having lost their fortune and died young. The mother then took a job to support her two younger brothers but later moved in with a maternal aunt, who drilled into her head that she was to be a social butterfly and attract a successful businessman for a mate. Which she did. Yet she never seemed particularly enamored with her husband.

In particular, her aunt told her she had to lose weight to be more attractive. She did that. She never again had a paying job, but was extremely active doing charity work and also painting. Her art was admired and was hung up prominently in their house, but Marsha only found out that she was the artist much later. I guess traditional women could work as long as they didn’t get paid and thereby threaten their husband’s traditional image. Mom did all this work despite having six young children.

The author writes that marriage and children were most important for mother as they generally were for her generation where she grew up. But were they really, or was she just following her family’s rules?

When Marsha was a teen Mom tried compulsively to get Marsha to do the same thing her aunt made her do - unsuccessfully. Marsh was compared negatively with her younger sister who followed the supposed family philosophy re marriage and work. In particular, Mom constantly nagged Marsha about losing weight. Marsha was the only child in the family with a weight problem, so perhaps that wasn’t “genetic.” Marsha writes that the thing she wanted to do more than anything was to gain her Mom’s approval, but somehow she couldn’t manage to do this one simple thing - that her Mother had been able to do - in order to get it.

Marsha writes clearly that she knew that Mom’s relationship with her great aunt was the reason her Mom was so critical of her, but she seems to not understand exactly what made her family act out this issue in the first place nor exactly how it might be transmitted from a previous generation to her. Again, her solution in DBT seems to be “radical acceptance” – you just use mindfulness to accept this reality without trying to change anything, and to stay calm.

If she were my patient, I would start to explore the possibility that she actually was doing what her mother seemed to need her to do - in effect acting out her mother’s repressed ambition, so clear in her non-family activities – so mother could experience her success vicariously. And then trying without success to put up with her Mom constantly invalidating it. Meanwhile, sister Aline was acting out the other side of conflict and appeared to be Mom’s favorite. Mom even told Aline to stay away from Marsha. Aline late apologized to Marsha for this but only after Mom had passed away.

When it comes to religion, Marsha’s description of her behavior seems even more conflicted. She was a practicing Roman Catholic throughout her life, and says that her mother “gave” that to her. However, in the book she frequently criticizes the church for such things as its rampant sexism and for the belief of the Pope’s infallibility. She disputes the circular argument heard by many fellow parishioners that God is real because it says so in the Bible. She later started to mix Catholic ideas about God with Zen Buddhist ideas about the ultimate oneness of everything in the universe in ways which are basically incomprehensible.

Further evidence of conflicts over beliefs and how they may have played into her issues regarding marriage: she couldn’t marry the guy who she most loved because he wanted to enter the priesthood. Even though he didn’t and eventually married. She wouldn’t marry her next boyfriend because he was an atheist. Going from one extreme to another and ending up in the same place - single - is a hallmark of an intrapsychic conflict.

Mixed messages from parents conflicted over the role of being parents is in my theory the hallmark of families with BPD members, and this one seems to qualify. Her mother having six children and no apparent career might be evidence for such a conflict. Dr. Linehan was hospitalized with self cutting and suicide threats for over two years just weeks before finishing high school. 

Problematic Parenting or Problematic Genes?

 

In an article in the Atlantic magazine, author and data scientist Seth Stephens-Davidowitz opines that in determining how parents affect their children in the long run, almost none of the decisions they make matter nearly as much as they think they do. He of course emphasizes their DNA and uses twin studies in discussing the nature-nurture debate, something I have covered extensively in my blogs.

He trots out the kind of story you often hear in these debates of two twin who were raised separately from the age of four weeks. They reunited at age 39 and found that they were each six feet tall and weighed 180 pounds; bit their nails and had tension headaches; owned a dog named Toy when they were kids; went on family vacations at the same beach in Florida; had worked part-time in law enforcement; and liked Miller Lite beer and Salem cigarettes. There was one notable difference: Jim Lewis named his firstborn James Alan, while Jim Springer named his James Allan. 

These are some very superficial similarities. Many involve things like their physical appearance, which is of course dictated by their genes. Tastes in food, assuming that they do not involve a false self, are also somewhat determined by genes.  The author also seems to assume this what these twins named their children was somehow coded in their DNA. I wonder how many hundreds of other twin pairs like this gave their children completely different names. Or where one bit their nails and the other did not.

A study suggests that such things as teaching kids cognitively-demanding games, such as chess, doesn’t make them smarter in the long term. A meta-analysis of bilingualism found that it has only small effects on a child’s cognitive performance.

The author does emphasize the importance of “the village” or neighborhood in which a child grows up in determining things like schooling and career opportunities, because they provide role models as well as money. Of course the village is divided into cliques with differing values, and to which people one chooses to associate may involve the influence of one's parents, but no matter. When it comes to parenting, he tells us the data shows that moms and dads should put more thought into the neighbors they surround their children with—and lighten up about everything else.

It’s hard to argue with these ideas, and a lot of parents do indeed need to lighten up and let their kids learn about themselves and the world. The problem here is that the author is completely ignoring a most important issue: interpersonal relationships and the rules by which people operate in their social context. In particular social roles, both functional and dysfunctional, and one’s freedom to self actualize versus having to behave in ways that stabilize family functioning. 

Children learn predictive models that determine who they drawn to and how to respond to them in various situations. Most of that becomes subconscious and automatic. Personality disorders and family dysfunction come from those. And the author doesn’t even mention adverse childhood experiences. My readers will know what I’m talking about here.

That’s a pretty big omission.

New Study Questions History of Childhood Trauma in Borderline Personality Disorder

Despite protestations in some quarters that it’s just a brain disorder and that’s all, almost all studies of subjects of borderline personality disorder (BPD) show a significant percentage of them were found to have a history of child abuse, including physical, sexual, and psychological. Since research subjects may not all be truthful about matters like that, the percentage is probably higher than those reported. Frank abuse is of not seen in all cases, of course. 

 

In getting to the bottom of the family dynamics of my psychotherapy patients over the last 40 year, I discovered that some of their parents are instead hyper-involved yet resentful helicopter parents who try to protect their children from any and all problems – which invalidates their children's ability to take care of anything on their own. Parents invalidating their kids’ thoughts and feelings, posited as one of the causes of the disorder by Marsha Linehan’s DBT – the predominant psychotherapy paradigm for the disorder – is an almost universal feature of BPD families.

 

A good meta-analysis (studies that combine the results of several study to add strength to the conclusions of any one study) that corroborates theoretical proposals that exposure to adverse life experiences is associated with BPD is “Childhood adversity and borderline personality disorder: a meta-analysis” by Porter et. al. in Acta Psychiatrica Scandinavia (2019).

 

A new study, however, seems to show that this is not the case (“Childhood trauma and borderline personality disorder traits: A discordant twin study” by Skaug, et al., Journal of Psychopathology and Clinical Science, (2019). But it has some of the same logical flaws I’ve documented in a previous post. It was a study of “discordant” twins (where one is healthier than the other) and was based on their self report using a structured interview called the Childhood Trauma Interview. Small but statistically significant associations between childhood trauma (CT) and BPD traits were initially found in the total sample. However, after controlling for “shared environmental” and genetic factors in the discordant twin pairs, the analyses showed little to no evidence for causal effects of CT on BPD traits. The authors concluded that the associations between CT and BPD traits stem from common genetic influences.

 

The elephant in the room here is the definition of “shared environment.” The assumption here is that both twins grew up in the same environment, which further presumes that their parents treated both of them the same. As anyone with a sibling or more than one child knows, this is nonsense. Differences in the way the parents treat the two children might even be exacerbated by the fact that one twin is healthier than the other, which could mean they had different parental responses to them at least some of the time. If you assume the shared environment is the same with parents treating both kids the same, of course genetic differences will stand out more. The study also ignores the fact that self reports about childhood abuse are often dishonest in order to go along with family rules about hiding such things from outsiders, so that its data in all likelihood also underestimates the prevalence of adverse childhood experiences, thereby minimizing any differences in the way each twin was treated.

Contact with Toxic Parents: Ambivalence Reigns

 

There are a plethora of self-help books out, including the one I wrote (pictured above), advising adult children of toxic parents on what to do. Some recommend cutting them off, some recommend keeping them at a distance, some recommend trying to set better boundaries, some talk about whether reconciliation is possible or not, and a few of them say it depends on the nature of the problems.

My own view, as most of my readers know, is to solve the problem of ongoing toxic parental behavior by researching the family history to identify shared internal conflicts, the reasons for them, and the effect of ambivalent double messages throughout at least three generations on everyone involved. Then, the object is to confront the issue head on by developing various strategies to empathically get past parents’ formidable defenses and come to some mutual understanding of why everyone is so miserable and what can be done to stop repetitive dysfunctional interactions. The goal is not reconciliation  per se but problem solving. Reconciliation and forgiveness is, however, however, a typical byproduct.

The psychotherapy research literature has had very little to say about this. It does come up in opinion pieces in such magazines as Psychology Today or The Psychotherapy Networker.

I think this whole question is a much bigger issue than it appears to be, and is a major cause of self-destructive or self defeating behavior, anxiety and unhappiness. How do I know? Well, a few years ago I started reading newspaper advice columns on the internet from four different advisors: Carolyn Hax, Amy Dickerson, Annie Lane, and Dear Abby. In order to maintain their readership, these columnists have to identify which letters are going to lead to a lot of public interest. If subjects pop up a lot, one might conclude that the problems discussed are very common.

And letters about this issue are exceeding common. People are constantly asking how to solve ongoing behavior from parents that is driving them crazy, whether they should reconcile with parents that have been already been cut off, whether to cut off toxic parents, guilt over a decision already made regarding a cut off, how to set boundaries, whether to reveal a history of child abuse to siblings and children, and how to stand up to parents without being disowned. My count of letters like this in the four columns was 28 in 2021 and 12 through April of this year. And I’m not even counting all the letters from parents who have been cut off by their children for “mysterious” reasons as I described in two previous posts.

Some writers are writing to justify their decisions on this matter, but their ambivalence about whatever decision they have made is just blaring. If they think their decision was so good, why are they writing about it? Some even want to warn people to watch out for therapists who recommend reconciliation, shouting the benefits of cut-offs from the rooftops. Do they think every situation is the same? And why do they feel the need to shout this out by writing to an advice columnist.

As I have said many times, cutting off an abusive parent is better than continued abuse, but those are not the only two options. My book discusses the third option for cases that do not involve significant physical or sexual abuse, and my psychotherapy model is for therapists to help all kinds of cases no matter how severe. The methods are not quick fixes, and the therapy is long term and often either not paid for by insurance or just flat out unavailable, since this therapy model has unfortunately not caught on. So the best solution can be very out of reach.

However, the danger of ongoing cut offs AND continuing abuse and toxicity is that the interpersonal and intrapsychic (in the mind) issues are not resolved but continuously reinforced by ANY family contact and consequently are seldom sufficiently repaired. Not to mention that the risks of passing them on to your own kids is quite high. 

The high degree of ambivalence about making or having made these decisions regarding ongoing contact shows how important family really is to just about everyone

The Effects of Mothers with a History of Depression on Their Offspring

Judith Morgan, Ph.D.

University of Pittsburg 

As my readers surely know, the nature-nurture debate in science continues unabated. Especially in psychiatry. When it comes to certain repetitive emotional reactions shown by a given individual, many in the field prefer to believe that the individual was just born that way. The truth, as described in Robert Sopolsky excellent book Behave,  is that we have hundreds or even thousands of genes that make certain behaviors either a little more or a little less likely. No complex human behavior is determined entirely by a gene or group of genes. We are also strongly programmed to tend to react in certain ways to the behavior of our kin group, although we can still make the difficult choice not to once we reach a certain age.

There is without a doubt a strong genetic component to true brain diseases like Major Depressive Disorder or schizophrenia, but the situation for other emotional reaction patterns is that they, IMO, are far more affected by the family environment than by any specific genes.

Some studies sure do point in this direction. For example, in a recent study published in Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, Judith Morgan, Ph.D., recruited 49 children aged six to eight without a history of psychiatric illness. Half the kids' mothers had a history of clinical depression, and half had no psychiatric history. To measure reward-related brain activity, children played a video game in which they guessed which of two doors contained a hidden token while they underwent functional magnetic resonance imaging (fMRI).

Depression may disrupt parents' capacity for emotional socialization, a process by which kids learn from their parents' reactions to their emotional responses. Positive socialization responses include acknowledgment, imitation, and elaboration, whereas negative or emotionally dampening parental responses may be dismissive, invalidating, or punitive.

Mothers participating in the study completed an extensive questionnaire designed to measure parental emotional socialization by presenting a dozen situational vignettes of children's displays of positive emotions and collecting parents' reactions to them. Children with a maternal history of depression were more likely to have reduced reward-related activity in a part of their brains that handles this, but only if their mothers reported less enthusiastic and more dampening responses to their children's positive emotions, the researchers found.

"In our study, mothers' own history of depression by itself was not related to altered brain responses to reward in early school-age children," said Dr. Morgan. "Instead, this history had an influence on children's brain responses only in combination with mothers' parenting behavior, such as the ability to acknowledge, imitate, or elaborate on their child's positive emotions."

Family Roles: A Form of Method Acting

 

When I was teaching psychotherapy techniques to psychiatry residents and psychology interns, one piece of advice I gave them ran counter to the advice most frequently given by other supervisors. I told them, when doing therapy with patients with personality disorders, to pay more attention to the words that the patient/client verbalizes than to their non-verbal expressions and body language. 

In general, body language is in fact usually more important than what a person says in determining how they really feel or what they really believe. This is true because, biologically, non-verbal communication evolved in our species long before language did, and became a more primal representation of what is going on inside of us.

 

So why do I give trainees the opposite advice? The fact that non-verbal behavior conveys more and more accurate information to another person than verbal behavior is precisely the point. People who have personality disorders are playing roles in their family. In a sense, they are acting! These people have developed a false self or persona that is one of the various roles I have described in prior posts – savior, avenger, go-between, spoiler, defective, loser, monster, covert caretaker, etc. In order to do this most effectively, one has to be a good actor, and therefore hide one’s true self – one’s actual beliefs and feelings which are not part of the act! Because role players have to be convincing, they are purposely giving off the wrong impression with their body language. How do they know to do that? Probably through trial and error.

 

Why do they become such good method actors? The simple explanation is that for them, playing the role as well as possible seems to be nearly a matter of life or death. Not playing the role leads to a form of existential terror called groundlessness. A person nonetheless does have the power to go ahead and exhibit their true selves in spite of this, but in dysfunctional families, doing so is terrifying. One of the things I learned in dealing with spoilers (borderline personality disorder) is that, whenever they feel that what they are doing is not working, that is when they start to self injure (cutting and burning themselves).

So what about their verbal behavior? Shouldn’t that also be misleading for the same reasons? Well yes it is. But there is a peculiarity of language that leads to my second piece of advice to beginning therapists: whenever patients say something that is a little ambiguous – when there is more than one way to interpret it – I tell them to at least think about the less obvious one. This is also the secret to solving the New York Times Sunday crossword puzzle, in which a lot of the clues can be interpreted in a bunch of different ways to throw solvers off.

For example, the mother of a nurse yelled at her, “I can’t believe you talk to doctors that way!” The nurse was far more outspoken than most people in her situation and often surprisingly got away with it. Of course, the nurse interpreted the mother’s remark as a criticism because of her tone of voice. But the words themselves contain no value judgment at all! I think the mother actually admired her daughter for being outspoken because she couldn’t be herself, but could not admit it. 

I also think the nurse knew that because she was in fact acting out successfully in that regard, and the mother was vicariously living through her. The reason the nurse got upset when Mom yelled at her was because the mother was now seemingly upset with her for doing the very thing that the mother seemed to want her to do in the first place. The ambiguity in the words Mom chose can give clues as to what Mom's real feelings are.

Are People with Borderline Personality Disorders Defective at Reading Others, Or Superior?

One of the current theories about what creates borderline personality disorder is that somehow they are defective in their ability to mentalize, or have an accurate “theory of mind.” This means they do a poor job of figuring out what is going on in the heads of other people. In studies, this is mostly found on tests where they are supposed to read faces or interpret videos of people in various activities. 

I always thought this idea was very amusing in light of the fact that, in my extensive experience speaking with other therapists as well as in my own experiences, these very same people are so good at drawing three particular responses from therapists: a sense of anxious guilt, anxious helplessness, or fury. They are so good at it that they make most therapists hate them. They can ascertain the therapist’s weak points, and then go right for the jugular. How can they be bad mentalizers if they can do that?

When you live in an unstable, confusing environment in which double messages are flying back and forth and you can’t really predict what mood a parent is going to be in when they drop in on you, you become better at reading others than most people so you can quickly adjust to any new contingencies. And as I have repeatedly pointed out, error management theory would predict that you would err on the over-reacting rather than under-reacting, because the consequences of minimizing parental guilt and hostility are so frightful. This normal tendency is then mistakenly seen as something pathological.

Another big issue in research in personality disorders that bears upon this issue is that when patients are in studies responding to various stimuli in the study situation, they may be responding with a false self or persona (as described by psychoanalysts Jung and Winnecott)—in this case, the spoiler. This is, as my readers know, a role I believe they are playing to maintain smooth family functioning (family homeostasis). This makes them look impaired when in fact they are not. Performance is not the same as ability, as I described in a previous post. If you are not a good actor in situations in which fooling people is paramount, you wouldn’t be very good at doing so.

And to effectively play the role of spoiler, you have to make yourself to be way more impaired than you actually are. In particular, you have to pretend that you lack the ability to see both the good and bad in people simultaneously (so-called “splitting”), or evaluate both their strengths belied by their reputation among therapists for being master manipulators!! Deficient mentalization, huh?

One new study (Bora, “A meta-analysis of theory of mind and 'mentalization' in borderline personality disorder: a true neuro-social-cognitive or  meta-social-cognitive impairment?, Psychological Medicine. 51(15):2541-2551, 2021 11). of so-called mentalization “abnormalities” was based on a review of the existing literature. The author just assumes that what the studies see is “maladaptive” and therefore abnormal, but found no evidence of any primary neuro-social cognitive deficit! Hardly surprising in light of what I just wrote about. Instead, the author attributes the imaginary abnormality to their “meta-social cognitive style,” whatever that is. Again, it’s as if these patients exist in some social vacuum where certain assumptions would always be completely highly adaptive for anyone who didn’t have a deficient “theory of mind.”

A second study (McLaren, V. et. al. "Hypermentalizing and Borderline Personality Disorder: a Meta-Analytic Review, American Journal of Psychotherapy 75(1): 21-31) looked at "hypermentalizing" - the tendency to overattribute mental states to other - and found it was common in a wide range of disorders rather than in borderline personality disorder in particular. 

Medication for Symptoms of Borderline Personality Disorder

A recent review of the literature on the use of medications in cases of people with borderline personality (BPD) disorder (“Pharmacological Treatments for Borderline Personality Disorder: A Systematic Review and Meta-Analysis.”  CNS Drugs. 35(10):1053-1067, 2021 10) concluded that “Despite the common use of pharmacotherapies for patients with BPD, the available evidence does not support the efficacy of pharmacotherapies alone to reduce the severity of BPD.” Additionally, “Second-generation antipsychotics, anticonvulsants, and antidepressants were not able to consistently reduce the severity of BPD.”

Well, duh. This is hardly surprising in light of the fact that personality disorders are primarily disorders of relationships and their subsequent effect on the mental state of participants in problematic interactions. Last I checked, medications do not fix relationships.

So are medications not indicated at all for people with this relatively common disorder? Well that’s nonsense as well, because sufferers often have other co-existing anxiety and mood syndromes (comorbid disorders) for which meds are most useful. The most common one in this population is panic disorder. One study showed that 40% of these people experienced panic attacks, but I think it’s much higher than that, at least in the patients who came to a psychiatrist like me for psychotherapy. It’s also true that rage attacks—another symptom of the disorder—are physiologically identical to panic attacks. You know, fight or flight.

I found out relatively early on that self injurious behavior like self-cutting or burning or bulimia often occurred when a patient found themselves in a hopeless bind in their families in which they felt it was imperative to do something to “fix” the situation but they felt helpless to do so. I discovered this the hard way. 

A patient would call me, often late at night, asking me what to do about something when they knew very well that I did not yet know enough about their situation to make any suggestions which would actually be helpful. If I dared to offer most anything, they immediately would know that I was full of crap. Talk about a sense of helplessness. I later figured out the best response in this situation was to say, “You don’t have to do anything right now. From what you’ve told me, this crisis will soon pass and be replaced by another crisis in short order.” Patients found this comment had a calming effect.

So what medications can reduce the chances of self injurious behavior by lowering the frequency of panic attacks? Oddly, when I first started private practice way back in 1979, a psychoanalyst (of all people) told me the secret: a combination of an antidepressant drug called an MAO inhibitor (this was before there were any Prozac-like drugs, which also fill the bill) with a long acting benzodiazepine like Clonazepam. Prescribing these worked far more quickly for reducing or even stopping self injurious behavior episodes than months of dialectical behavior therapy, and was quite effective.

Naturally, I was criticized for prescribing this combination. With MAOI’s, the patient would have to avoid certain foods and drugs which interact with these medications and cause an attack of severe high blood pressure. (Luckily with the Prozac-like SSRI’s, this is no longer an issue). “You mean you trusted these people to keep to the diet?!? I was asked. My answer, “Yes I do if they tell me they will stick to the diet.” Yes, and if they told me that, lo and behold, they did! I had only one patient take a proscribed medication, ending up in the ER, and I took him off the MAOI immediately.

“And benzo’s can be abused!” was the next attack. Yes, so can pretty much anything. Once again, if the patient agreed to take the meds as prescribed, and I prescribed an adequate dose (patients who were given sub-therapeutic doses tended to raise the dose on their own), seemed not to abuse them. I received further confirmation of this belief when states started to produce a data base of prescriptions for drugs of abuse, and I saw that my patients were only rarely getting them from another doc (in which case I immediately tapered them off the drug). Luckily, with the exception of Xanax and in methadone treatment centers, there is no large street market offering my patients benzo’s.

So are there studies that prove this combination is effective in the way I say? Well I’ve been on the lookout for such studies for decades, and there literally aren’t any! The closest that come are those that study SSRI’s by themselves in this population without the necessary augmentation. They show some very small effects on self-injury, but nothing substantial. Oddly, I asked the guy who did most of these studies if he ever considered doing the add-on one, and he looked at me as if he didn’t understand what I was talking about. He later gave a talk on BPD and chemicals (neurotransmitters) that help brain cells communicate, and he discussed several of them. Except one —GABA—which is the most important one in anxiety and the target of benzo drugs.

Verrrrry interrrresssssting.

Hidden Altruism in Repetitive Family Interactions

 

In a recent Dear Abby advice column from 10/26/21,  a mother who had been an addict when her daughter was young complains about the guilt trips the daughter always seems to lay on her. Abby’s interpretation as to the possible motives for the daughter’s behavior is the seemingly common-sense one that most people – and most psychotherapists for that matter - would come up with: that the daughter was acting out of selfish needs.

 

Being the contrarian that I am, I discovered that selfishness is often actually a cover for altruistic self-sacrifice, and that the daughter is giving mom what mom seems to need from her. The mother’s obsessive guilt and her repeatedly and nearly constantly trying to fix her daughter might very well be the reason the daughter is doing this.

 

Now of course, from just a paragraph description in a letter I can’t be certain of my interpretation in this particular case, and there might be several other issues operating simultaneously that might be making this situation far more complicated than my formulation would suggest. The daughters’ brothers being perceived as the favorites, which is mentioned in the letter, might be one of them. The mother may have gender issues which might conceivably be involved.  And we don’t know anything about Mom’s former behavior, let alone her family dynamics

But if we could get the truth out of these people – always an iffy proposition -  I’d be willing to bet that I am at the very least on the right track. I have put in italics the part of the letter that I think gives it away. My hypothesis would be my starting point as her therapist in trying to understand what exactly is going on, and why.

 

ABBY: I'm the mother of a 36-year-old daughter. She claims I treat her younger brothers better than I treat her. I am a recovering addict -- clean for 20-plus years. I was in active addiction for nine years when she was a teenager, and she has never let that go. She constantly tells me how "unfair" I am, that I never make time for her and that I don't validate her feelings. I have apologized many times and tried to show her I don't treat her siblings differently. I schedule "us" time, but this is an ongoing battle, and I'm at a loss about how to fix it. How do I show her there's no difference in the way I treat any of them? How do I reassure her that her feelings are validated? This has caused me many tearful nights. -- WANTING SERENITY BACK

 

In reply Abby says she thinks this mother “created an emptiness in her daughter “that the mom may not be able to fill,” and that the daughter is “punishing” the mom for her former behavior. I submit that the daughter is actually giving Mom what Mom's endless guilt seems to be begging for: More and more guilt! Mom’s obsessive apologies would then trigger this pattern again and again, leading to the daughter heaping on more and more guilt leading to more apologies and so on in a vicious circle.

 

Each member of the duo thinks the other one needs this interaction while discounting their own contribution to the pattern. They have to cover up their own role in order to continue playing it effectively, both for the stabilization of a parent. Mom’s history of substance abuse and neglecting children would, under this scenario, be a role she was playing for her parents.